Available online at www.sciencedirect.

com

Comprehensive Psychiatry 53 (2012) 562 – 568

www.elsevier.com/locate/comppsych

Skin picking and trichotillomania in adults

with obsessive-compulsive disorder
Lucas Lovato a,⁎, Ygor Arzeno Ferrão b , Dan J. Stein c , Roseli G. Shavitt d ,
Leonardo F. Fontenelle e , Analise Vivan a , Eurípedes Constantino Miguel d ,
Aristides Volpato Cordioli a
a
Federal University of Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Psychiatry, Porto Alegre, RS, Brazil
b
Federal University of Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
c
Department of Psychiatry, University of Cape Town, Groote Schuur Hospital J2, Cape Town, South Africa
d
University of São Paulo Medical School, Institute and Department of Psychiatry, São Paulo, SP, Brazil
e
Federal University of Rio de Janeiro, Department of Psychiatry and Mental Health, Institute of Community Healthy, Fluminense Federal University, and
D'Or Institute for Research and Education,Rio de Janeiro, RJ, Brazil

Abstract

The objective of this study was to compare patients with obsessive-compulsive disorder (OCD) associated with pathologic skin picking
(PSP) and/or trichotillomania, and patients with OCD without such comorbidities, for demographic and clinical characteristics. We assessed
901 individuals with a primary diagnosis of OCD, using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) Axis I disorders. Diagnoses of PSP and trichotillomania were made in 16.3% and 4.9% of the sample,
respectively. After the logistic regression analysis, the following factors retained an association with OCD-PSP/trichotillomania: younger
(odds ratio [OR] = 0.979; P = .047), younger at the onset of compulsive symptoms (OR = 0.941; P = .007), woman (OR = 2.538; P b .001),
with a higher level of education (OR = 1.055; P = .025), and with comorbid body dysmorphic disorder (OR = 2.363; P = .004). These
findings support the idea that OCD accompanied by PSP/trichotillomania characterizes a specific subgroup.
© 2012 Elsevier Inc. All rights reserved.

1. Introduction psychopathology/pathophysiology of OCD and patterns of

The hallmark features of obsessive-compulsive disorder
(OCD) are intrusive and persistent thoughts (obsessions) that
evoke anxiety, followed by ritualized behaviors (compul-
sions) intended to relieve anxiety [1]. Despite this general
diagnostic concept, there is considerable heterogeneity in
clinical presentation, which hinders the interpretation of
findings from genetic, neuroimaging, and treatment studies
[2,3]. Various authors have found specific characteristics
according to age at onset [4-6], patterns of comorbidity [4,6],
sex [7], and level of insight [8].
Delineating OCD subgroups that are more homogeneous
has been the objective of various studies focusing on the
⁎ Corresponding author. Federal University of Rio Grande do Sul,
Hospital de Clínicas de Porto Alegre Dept. of Psychiatry. Rua João Abbott,
333/503, Porto Alegre, RS, Brazil - CEP 90460-150.
E-mail address: medicolucaslovato@gmail.com (L. Lovato).
0010-440X/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2011.06.008
treatment response [9-13]. The findings of many such
studies, such as those investigating the genetics of OCD [3],
support the use of the symptom dimension approach. Hasler
et al [14] suggested that specific OC symptom (OCS)
dimensions are more heritable than is OCD in general, and
van Grootheest et al [15] found that specific genetic
components are related to the contamination dimension. In
addition, neurobiological studies have found specific
differences between distinct subgroups. Saxena et al [16]
found that the patterns of cerebral glucose metabolism differ
between OCD patients with hoarding and those without.
Viswanath et al [17] found evidence that familial OCD
differs from sporadic OCD in age of onset, type of OCS,
pattern of comorbidity, and treatment response. It has been
suggested that OCD subgroups can be defined on the basis of
the patterns of comorbidity [18-20].
According to current classification of mental disorders,
impulse control disorders (ICDs) constitute a heterogeneous
 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568
group of psychiatric disorders, including trichotillomania,
pathologic gambling, intermittent explosive disorder, pyro-
mania, and kleptomania. Such disorders are characterized by
a failure to resist impulses or temptations to perform some act
that is harmful to oneself or others, by an increasing sense of
tension before acting, and by a sense of pleasure, gratifica-
tion, or relief at the time of committing the act or shortly
thereafter [1]. Three studies in particular have explored the
issue of comorbidity between OCD and ICDs in adult
patients. Fontenelle et al [21] studied 45 patients with OCD
and concluded that OCS severity was greater in those with at
least one comorbid ICD, who also required a greater number
of changes in the selective serotonin reuptake inhibitor
treatment regimen during follow-up. In addition, Matsunaga
et al [22] assessed 153 adult patients with OCD and found that
subjects with comorbid ICD differed from other patients with
OCD on a range of demographic and clinical features, the
former group showing more pervasive and severe psychopa-
thology, as well as poorer treatment outcomes. In the largest
such study, involving 293 patients, Grant et al [23] concluded
that symptom severity, functioning, and quality of life were
worse among individuals with OCD and a concomitant ICD
than among those with OCD and no ICD.
It is possible that the current classification of ICD includes
disorders that are quite heterogeneous in origin. Therefore, the
co-occurrence of a specific ICD might have a singular impact
on the expression of OCD. Grant et al [23] suggested that
certain ICDs, including pathologic skin picking (PSP) and
trichotillomania, are particularly common among individuals
with OCD. In a recent family study of OCD, PSP and
trichotillomania were collectively designated “grooming dis-
orders” (GDs) because of the nature of the repetitive behaviors
involved. This paper indicates that pathologic grooming
behaviors are transmitted in families of patients with OCD
and can be considered part of a familial OCD spectrum [24]. In
a sample of pediatric patients with OCD, Flessner et al [25]
observed high comorbidity with grooming behaviors, with
distinct characteristics, and suggested that the identification of
this patient subgroup calls for specific changes in treatment
manuals. Knowledge of this putative specific OCD subgroup
could guide future OCD treatment practices, such as including
habit reversal techniques in cognitive-behavioral therapy, as
well as encouraging researchers to evaluate specific pharma-
cologic agents (such as modulators of the dopaminergic
system) in clinical trials [26,27]. Accordingly, genetic and
neurobiological studies should be conducted to further
elucidate the psychopathology of OCD-related disorders.
The objective of the present study was to determine
whether patients with OCD and GDs (PSP or trichotilloma-
nia) differ from those with other ICDs and those without
such comorbidities, in sociodemographic and clinical
characteristics, as well as to understand the impact that
certain ICDs have on the phenomenology of OCD. The
hypothesis is that OCD that co-occurs with GD may
constitute a specific subgroup that could be important in
the assessment, management, and prognosis.
563
2. Methods
2.1. Sample
This was a cross-sectional study involving 901 in-
dividuals who participated in the Brazilian Research
Consortium on Obsessive-Compulsive Spectrum Disorders
(BRC-OCSD) project between 2005 and 2009 [28]. The
BRC-OCSD project involves 7 university hospitals in 6
different Brazilian cities. All 7 hospitals are dedicated to
OCD treatment and research.
We applied the following inclusion criteria: having
received a primary diagnosis of OCD, as defined in the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV), and being enrolled at any of the 7
BRC-OCSD centers. We used the Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID-I), to confirm
the diagnosis [29]. Patients who met the DSM-IV diagnostic
criteria for schizophrenia were excluded. Individuals were
referred to the project from health care clinics (primary or
secondary), private psychiatric services, Web sites, media
announcements, self-help groups, and the Brazilian Associa-
tion for Tourette Syndrome, Tics, and Obsessive-Compulsive
Disorder. Additional details regarding BRC-OCSD proce-
dures are available in the study conducted by Miguel et al [28].
The present study was approved by the institutional review
boards at each BRC-OCSD center. All participants gave
written informed consent.
2.2. Assessment
The study protocol included sociodemographic data and a
review of academic, professional, medical, and psychiatric
histories. The following instruments were used [29-34]: the
SCID-I, with additional modules for tics and ICDs [30];
the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS);
the Dimensional Yale-Brown Obsessive-Compulsive Scale
(DY-BOCS); the Beck Depression Inventory; and the Beck
Anxiety Inventory. Researchers at each of the BRC-OCSD
centers were trained to use the SCID-I, Y-BOCS, and DY-
BOCS, all of which have excellent interrater reliability, as
described by Miguel et al [28].
2.3. Statistical analysis
The patients were divided into three groups: OCD without
any ICD (pure OCD), OCD with at least one GD (OCD+GD),
and OCD with another ICD but without any GD (OCD+
ICD/noGD). Patients with multiple ICDs were excluded if
one of those ICDs was a GD. The categorical variables were
expressed as absolute and relative frequencies. The contin-
uous variables were expressed as mean ± standard deviation
or as median (range), depending on the distribution of data
(normality assessed by the Kolmogorov-Smirnov test).
To compare categorical variables among the three groups,
we used the χ 2 test and post hoc multiple comparisons with
Tukey honestly significant difference test. For continuous
variables, we used analysis of variance and Scheffé post hoc
564 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568

test, as necessary. The Kruskal-Wallis test and Dunn test were
used for continuous variables with non-normal distribution.
Using previous analysis, we then compared the OCD+GD
and OCD without GD groups. Variables with a value of P b .10
in this step were included in a multiple logistic regression model
to determine the factors independently associated with GD.
The program Statistical Package for the Social Sciences,
version 17.0 (SPSS Inc, Chicago, IL) was used. The level of
significance was set at P b .05.
3. Results
3.1. Demographics characteristics and comorbidities
Of the 901 patients studied, 516 (57.3%) were women, 380
(42.2%) were single or divorced, and 555 (61.6%) worked or
studied. The mean age was 34.4 ± 12.7 years. For comorbid
ICDs, 614 (68.1%) presented with OCD only, 121 (13.4%)
had OCD+GD, and 114 (12.7%) had OCD+ICD/noGD. The
overall prevalence of ICDs was 31.9%. Of the 901 patients
with OCD, 52 (5.8%) had a GD and another ICD, and those
patients were excluded from the statistical analysis. The ICDs
were distributed as follows: PSP in 147 (16.3%), impulsive
buying disorder in 73 (8.1%), intermittent explosive disorder
in 58 (6.4%), trichotillomania in 44 (4.9%), kleptomania in 21
(2.3%), nonparaphilic sexual addiction in 20 (2.2%), Internet
addiction in 20 (2.2%), pyromania in 3 (0.3%), pathologic
gambling in 4 (0.4%), and video game addiction in 4 (0.4%).
3.2. Sociodemographic and clinical characteristics of 3
groups: OCD, OCD+GD, and OCD+ICD/noGD
Table 1 shows the sociodemographic and clinical
characteristics of the patients in the pure OCD, OCD+GD,
and OCD+ICD/noGD groups. Compared with patients in the
pure OCD group, those in the OCD+GD group were more
often women, single (unmarried or divorced), and younger, as

Table 1
Sociodemographic and clinical characteristics of obsessive-compulsive disorder, with and without grooming disorders and other impulse control disorders
Characteristic OCD Statistical test (P)
Pure (n = 614) With GD (n = 121) With ICD/no GD (n = 114)
Female sex, n (%) 332 (54.1)* 88 (72.7)* ,#
57 (50.0) # χ 2 = 16.34 (b.001)
Unemployed, n (%) 305 (49.8) 69 (57.0) 52 (46.0) χ 2 = 3.07 (.216)
Single or divorced, n (%) 367 (59.8)* 90 (74.4)* 71 (62.3) χ 2 = 9.17 (.010)
Age, y, mean ± SD 35.0 ± 13.1* 31.0 ± 11.8* ,# 35.7 ± 11.7 # F2.85 = 5.37 (.005)
Schooling, y, mean ± SD 14.4 ± 5.1 15.3 ± 4.4 14.1 ± 5.2 F2.85 = 1.81 (.164)
Age at OCS onset, y, mean ± SD 13.13 ± 7.68* 10.12 ± 4.82* 12.02 ± 6.41 F2.85 = 10.19 (b.001)
Age at compulsions onset, y, mean ± SD 13.79 ± 8.25* 10.27 ± 4.78* 12.35 ± 6.43 F2.85 = 11.20 (b.001)
Y-BOCS
Total score, mean ± SD 24.82 (8.23) 26.29 (6.31) 25.77 (7.23) F2.85 = 2.01 (.135)
Obsessions score, mean ± SD 12.30 (4.29)* 13.36 (4.16)* 12.88 (3.60) F2.85 = 3.62 (.027)
Compulsions score, mean ± SD 12.52 (4.49) 12.93 (4.44) 12.90 (4.15) F2.85 = 0.69 (.505)
DY-BOCS
Aggressiveness
Presence, n (%) 393 (64.0) 91 (75.2) 78 (68.4) χ 2 = 5.96 (.051)
Severity, median (range) 4 (0-9)* ,# 7 (0-10)* 7 (0-10) # χ 2 (KW) = 13.72 (.001)
Sexual/religious
Presence, n (%) 321 (52.3) 71 (58.7) 67 (58.8) χ 2 = 2.84 (.242)
Severity, median (range) 0 (0-8) 4 (0-9) 6 (0-9) χ 2 (KW) = 6.42 (.040)
Symmetry
Presence, n (%) 524 (85.3) 111 (91.7) 103 (90.4) χ 22 = 4.99 (.082)
Severity, median (range) 8 (3-11)* 9 (6-11)* 9 (5-12) χ 2 (KW) = 8.68 (.013)
Contamination
Presence, n (%) 446 (72.6) 89 (73.6) 86 (75.4) χ 2 = 0.40 (.820)
Severity, median (range) 7 (0-11) 8 (0-11) 9 (2-12) χ 2 (KW) = 5.83 (.054)
Hoarding
Presence, n (%) 287 (46.7)* 73 (60.3)* 66 (57.9) χ2 = 10.60 (.005)
Severity, median (range) 0 (0-6)* ,# 3 (0-7)* 3 (0-8) # χ2 (KW) = 12.35 (.002)
Family history of OCD, n (%) 304 (49.6) 72 (59.5)* 49 (43.0)* χ2 = 6.65 (.036)
Family history of tics, n (%) 110 (19.1)* 29 (25.0) 32 (28.8)* χ2 = 6.31 (.043)
Tic disorders, n (%) 164 (26.7) 40 (33.1) 39 (34.2) χ2 = 4.01 (.135)
Body dysmorphic disorder, n (%) 42 (6.8)* ,# 26 (21.5)* 21 (18.4) # χ2 = 31.95 (b.001)
Suicidality
Current ideation, n (%) 196 (33.7)* 46 (39.3) 53 (47.7)* χ 2 = 8.382 (.015)
Previous attempt, n (%) 49 (8.4)* ,# 14 (12.0)* 19 (17.1) # χ 2 = 8.22
Beck Depression Inventory, mean ± SD 14.8 ± 11.5* ,# 17.7 ± 11.3* 19.7 ± 11.5 # F = 10.48 (b.001)
Beck Anxiety Inventory, mean ± SD 14.3 ± 11.5* ,# 17.5 ± 11.6* 18.4 ± 10.8 # F = 8.64 (b.001)
F indicates analysis of variance followed by Scheffé post hoc test; KW, Kruskal-Wallis test.
Asterisk (*) and number sign (#) indicate difference between the groups (P b .05).
 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568 565

Table 2 trichotillomania was 13.3% and 6.6%, respectively [21],

Logistic regression analysis of factors related to obsessive-compulsive whereas Matsunaga et al found that 12% of their patients
disorder with comorbid grooming disorder.
exhibited self-injurious behaviors (including PSP) and 5%
Variable P OR 95% confidence interval had trichotillomania [22]. In another study, Flessner et al
Woman b.001 2.538 1.561-4.127 [25] studied a sample of pediatric patients with OCD and
Current age .047 0.979 0.959-0.999 found that 21.3% also had GDs (15.9% with PSP and 5.3%
Having a steady partner .140 0.683 0.411-1.133
with trichotillomania). Our results differ from those of a
Level of education .025 1.055 1.007-1.105
Age at compulsion onset .007 0.941 0.901-0.984 study conducted by Grant et al [23], who identified ICDs in
Y-BOCS obsessions .986 1.001 0.936-1.069 only 11% of their sample, 7.8% with PSP, and 1% with
DY-BOCS trichotillomania. Those authors did not include compulsive
Aggressiveness buying and intermittent explosive disorder, conditions that,
Presence .805 1.099 0.521-2.320
together, accounted for 14.5% of ICDs observed in our
Severity .558 1.021 0.951-1.097
Symmetry sample. Although Fontenelle et al [21] included alcohol
Presence .875 0.922 0.337-2.523 abuse as an ICD and Matsunaga et al [22] listed personality
Severity .813 1.008 0.940-1.082 disorders as ICDs, neither condition is officially listed as an
Hoarding ICD in the DSM-IV-TR. Despite similar findings, there were
Presence .130 1.649 0.864-3.150
methodical differences among the aforementioned studies.
Severity .415 0.966 0.890-1.049
Family history of OCD .228 1.317 0.842-2.061 Previous studies have suggested that OCD is associated
Body Dysmorphic Disorder .004 2.363 1.323-4.219 with GDs (including PSP and trichotillomania) but not with
Beck Anxiety Inventory .302 1.014 0.988-1.041 other ICDs, such as pathologic gambling and kleptomania
Beck Depression Inventory .880 0.998 0.972-1.025 [24,35-46]. In the present study, logistic regression analysis
revealed that the two factors most strongly associated with
OCD+GD were being woman and having comorbid BDD.
well as having been younger at the onset of OCS and of
We found that women accounted for 72.7% of the patients
compulsions; scoring higher for obsessions on the Y-BOCS;
in the OCD+GD group. Other studies have also found a
scoring higher for aggression, symmetry, and hoarding on the
predominance of women among individuals with PSP and,
DY-BOCS; more often presenting with body dysmorphic
among those with trichotillomania, women accounting for
disorder (BDD); having more often attempted suicide; and
87.1% to 94.1% and up to 93.2%, respectively [41,47-49].
scoring higher on the Beck Depression Inventory and Beck
However, in the general population, there are no apparent
Anxiety Inventory. Compared with patients in the OCD
sex differences, or women are only slightly more predom-
+ICD/noGD group, those in the OCD+GD group were also
inant, in OCD prevalence [50-53]. Sex-related differences in
more often women and at younger, as well as having been
OCS and comorbid disorders have been described and may
younger at the onset of compulsions and more often having a
be a sex-related reflection of the expression of the OCD
family history of OCD.
phenotype [7,54-58].
3.3. Logistic regression A diagnosis of BDD also emerged as an independent
factor associated with GDs in our OCD sample. We found
After the logistic regression, the following factors that BDD was present in 21.5% of patients with OCD with
continued to be associated with OCD+GD (Table 2): an accompanying GD and in 8.7% of those without. The
younger (P = .047), younger at the onset of compulsions (P prevalence of BDD in the general population ranges from
= .007), woman (P b .001), with a higher level of education (P 1% to 2% [59-61]. That GDs and BDD are both associated
= .025), and with comorbid BDD (P = .004). Age at OCS with OCD suggests that these disorders should be
onset was not entered into the regression model because of considered OCD spectrum disorders. It should be borne
the collinearity with age at the onset of compulsions. in mind, however, that PSP can be also part of the clinical
profile of BDD. Grant et al [23] observed secondary PSP
4. Discussion in 36.9% of a sample of individuals with BDD, similar to
the 26.8% reported by Phillips et al [62]. However, the
In the present study, we found that 287 (31.9%) of the 901 relationship between PSP and BDD was not evaluated in
adult patients with OCD evaluated had at least one current our sample.
ICD. This is similar to the 35.5% and 29.0% reported by In the present study, we found that patients with OCD and
Fontenelle et al and Matsunaga et al, respectively [21,22]. In GDs were younger at the onset of compulsive symptoms/
our sample, the most common ICD was PSP (in 16.3%), OCS onset (around 10 years) than were those without
followed by compulsive buying (in 8.1%) and intermittent (approximately 10 years vs approximately 13 years). This
explosive disorder (in 6.4%). There were 173 patients leads us to conjecture that the clinical association between
(19.2%) with at least one GD: 17 (16.3%) with PSP, 44 GDs and OCD in these patients reflects major early risk
(4.9%) with trichotillomania, and 18 (2.0%) with both. factors that contribute to the expression of both disorders
Fontenelle et al found that the prevalence of PSP and during specific periods of development. Repetitive behaviors
566 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568
in GDs resemble those associated with early-onset OCD [6];
that is, instead of being performed to neutralize an obsession,
they are frequently performed to relieve a sensation or an
uncomfortable feeling or are repeated until the individual
achieves the “just right” feeling [63,64].
Other minor findings also retained statistical significance
after logistic regression model and might merit discussion as
points that warrant further investigation, although the
associations did not rise to the level of clinical relevance.
Patients in the OCD+GD group were younger than those in the
pure OCD group, a finding that could be explained by greater
severity and the consequent earlier treatment seeking. For
example, PSP usually causes major skin damage, leading to
aesthetic problems and dermatologic infections, which require
complex, immediate medical treatment [40,65]. A higher level
of education, as was also observed for patients with OCD+GD,
might also result in early treatment seeking behavior.
The present study has certain limitations. The cross-
sectional study design, and that we did not establish the
chronology among OCD, GDs, and BDD in their onset,
prevents us from making any causal inferences about which
disorders are primary and which are secondary. Although the
subjects of our study were recruited from multiple treatment
sites, a large percentage were recruited from treatment studies
conducted at referral centers or private offices. In addition,
we did not collect any data regarding severity or clinical
outcomes related to trichotillomania and PSP. A further
limitation is that we did not include a group of healthy
controls. However, on the basis of the reported prevalence of
ICDs/GDs in community samples, that observed in our OCD
sample (31.9%) seems relatively high. In a population-based
study, Kessler et al [66] found that the prevalence of ICDs
was 8.9%. In nonclinical samples (of scholars, dermatologic
subjects, and general populations), the reported prevalence of
PSP is 2.7% to 5.4% [67-69]. The reported prevalence of
trichotillomania in the general population is 1.0% to 3.5%
[70,71], also lower than the 4.9% found in our study.
In conclusion, we found a high prevalence of GDs
(primarily PSP and trichotillomania) in a sample of adult
patients with OCD. The patients with OCD and GDs were
predominantly young women in whom the onset of
compulsive symptoms had occurred early in life, and the
principal comorbidity was BDD. These data suggest that the
combination of OCD and GD constitutes an OCD subgroup
with definite sociodemographic and clinical features. Future
studies should investigate the genetics, neurobiology, and
treatment responses of such patients, to confirm our findings.
References
[1] American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 4th Ed. Text Rev. Washington (DC): American
Psychiatric Association Press; 2000.
[2] de Mathis MA, Diniz JB, do Rosário MC, Torres AR, Hoexter M, Hasler
G, et al, What is the optimal way to subdivide obsessive-compulsive
disorder? CNS Spectr. 2006;11(10):762-8, 771-4, 776-9.
[3] Katerberg H, Delucchi KL, Stewart SE, Lochner C, Denys DA, Stack
DE, et al. Symptom dimensions in OCD: item-level factor analysis and
heritability estimates. Behav Genet 2010;40(4):505-17.
[4] Swedo SE, Rapoport JL, Leonard HL, Lenane M, Cheslow D.
Obsessive compulsive disorders in children and adolescents: clinical
phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;
46:335-43.
[5] Hanna GL. Demographic and clinical features of obsessive-compulsive
disorder in children and adolescents. J Am Acad Child Adolesc
Psychiatry 1995;34(1):19-27.
[6] Rosario-Campos MC, Leckman JF, Mercadante MT, Shavitt R, Prado
HS, Sada P, et al. Adults with early-onset obsessive-compulsive
disorder. Am J Psychiatry 2001;158(11):1899-903.
[7] Torresan RC, Ramos-Cerqueira AT, de Mathis MA, Diniz JB, Ferrão
YA, Miguel EC, et al. Sex differences in the phenotypic expression of
obsessive-compulsive disorder: an exploratory study from Brazil.
Compr Psychiatry 2009;50(1):63-9.
[8] Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the
diagnostic criteria and possible subtypes and dimensional specifiers for
DSM-V. Depress Anxiety 2010;27(6):507-27.
[9] Feinstein SB, Fallon BA, Petkova E, Liebowitz MR. Item-by-item
factor analysis of the Yale-Brown Obsessive-Compulsive Scale
symptom checklist. J Neuropsychiatry Clin Neurosci 2003;15:
187-93.
[10] Lochner C, Stein DJ. Heterogeneity of obsessive-compulsive disorder:
a literature review. Harv Rev Psychiatry 2003;11:113-32.
[11] Hounie AG, Brotto AS, Diniz J, Chacon PJ, Miguel EC. Transtorno
obsessivo-compulsivo: possíveis subtipos. Rev Bras Psiquiatr 2001;
23(Supl 2):13-6.
[12] Leckman JF, Rauch SL, Mataix-Cols D. Symptom dimensions in
obsessive-compulsive disorder: implications for the DSM-V. CNS
Spectr. 2007;12(5):376-87, 400.
[13] McDougle CJ, Goodman WK, Leckman JF, Lee NC, Heninger GR,
Price LH. Haloperidol addition in fluvoxamine-refractory obsessive-
compulsive disorder. A double-blind, placebo-controlled study in
patients with and without tics. Arch Gen Psychiatry 1994;51(4):
302-8.
[14] Hasler G, Pinto A, Greenberg BD, et al. Familiality of factor
analysis-derived YBOCS dimensions in OCD-affected sibling pairs
from the OCD Collaborative Genetics Study. Biol Psychiatry 2007;
61:617-25.
[15] van Grootheest DS, Boomsma DI, Hettema JM, et al. Heritability of
obsessive-compulsive symptom dimensions. Am J Med Genet B
Neuropsychiatr Genet 2008;147B:473-8.
[16] Saxena S, Brody AL, Maidment KM, Smith EC, Zohrabi N, Katz E,
Baker SK, Baxter Jr LR. Cerebral glucose metabolism in obsessive-
compulsive hoarding. Am J Psychiatry 2004;161(6):1038-48.
[17] Viswanath B, Narayanaswamy JC, Cherian AV, Reddy YC,
Math SB. Is familial obsessive-compulsive disorder different from
sporadic obsessive-compulsive disorder? A comparison of clinical
characteristics, comorbidity and treatment response. Psychopatholo-
gy 2011;44:83-9.
[18] Holzer JC, Goodman WK, McDougle CJ, Baer L, Boyarsky BK,
Leckman JF, et al. Obsessive-compulsive disorder with and without a
chronic tic disorder. A comparison of symptoms in 70 patients. Br J
Psychiatry 1994;164:469-73.
[19] Nestadt G, Addington A, Samuels J, Liang KY, Bienvenu OJ, Riddle
M, et al. The identification of OCD-related subgroups based on
comorbidity. Biol Psychiatry 2003;53(10):914-20.
[20] Nestadt G, Di CZ, Riddle MA, Grados MA, Greenberg BD, Fyer
AJ, et al. Obsessive-compulsive disorder: subclassification based on
co-morbidity. Psychol Med 2009;39(9):1491-501.
[21] Fontenelle LF, Mendlowicz MV, Versiani M. Impulse control
disorders in patients with obsessive-compulsive disorder. Psychiatry
Clin Neurosci 2005;59:30-7.
 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568
[22] Matsunaga H, Kiriike N, Matsui T, Oya K, Okino K, Stein DJ.
Impulsive disorders in Japanese adult patients with obsessive-
compulsive disorder. Comp Psychiatry 2005;46:43-9.
[23] Grant JE, Mancebo MC, Pinto A, Eisen JL, Rasmussen SA. Impulse
control disorders in adults with obsessive compulsive disorder. J
Psychiatr Res 2006;40:494-501.
[24] Bienvenu OJ, Samuels J, Riddle MA, Hoehn-Saric R, Liang KY,
Cullen BAM, et al. The relationship of obsessive-compulsive disorder
to possible spectrum disorders: results from a family study. Biol
Psychiatry 2000;48:287-93.
[25] Flessner CA, Berman N, Garcia A, Freeman JB, Leonard HL. Symptom
profiles in pediatric obsessive compulsive disorder (OCD): the effects
of comorbid grooming conditions. J Anxiety Disord 2009;23(6):753-9.
[26] Fu Y, Zhao Y, Luan W, Dong LY, Dong Y, Lai B, Zhu Y, Zheng P.
Sigma-1 receptors amplify dopamine D1 receptor signaling at
presynaptic sites in the prelimbic cortex. Biochimica et Biophysica
Acta 2010;1803:1396-408.
[27] Villard V, Meunier J, Chevallier N, Maurice T. Pharmacological
interaction with the sigma1 (σ1)-receptor in the acute behavioral
effects of antidepressants. J Pharmacol Sci 2011;115:279-92.
[28] Miguel EC, Ferrão YA, Rosário MC, de Mathis MA, Torres AR,
Fontenelle LF, et al. The Brazilian Research Consortium on Obsessive-
Compulsive Spectrum Disorders: recruitment, assessment instruments,
methods for the development of multicenter collaborative studies and
preliminary results. Rev Bras Psiquiatr 2008;30(3):185-96.
[29] First MB, Spitzer RL, Gibbon M, Williams JB. Structured Clinical
Interview for DSM-IV Axis I Disorders: Clinical Version (SCID-CV).
Washington, DC: American Psychiatric Press; 1997.
[30] First MB. Structural Clinical Interview for DSM-IV-TR Impulse
Control Disorders Not Elsewhere Classified (SCID-TCIm). Biometrics
Research Department; New York State Psychiatric Institute; 2004.
[31] Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill
CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development,
use, and reliability. Arch Gen Psychiatry 1989;46(11):1006-11.
[32] Rosario-Campos MC, Miguel EC, Quatrano S, Chacon P, Ferrao Y,
Findley D, et al. The Dimensional Yale-Brown Obsessive-Compulsive
Scale (DY-BOCS): an instrument for assessing obsessive-compulsive
symptom dimensions. Mol Psychiatry 2006;11(5):495-504.
[33] Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory
for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
[34] Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring
clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;
56(6):893-7.
[35] Cullen BA, Samuels JF, Beinvenu OJ, Grados M, Hoehn-Saric R,
Hahn J, et al. The relationship of pathologic skin picking to obsessive-
compulsive disorder. J Nerv Ment Dis 2001;189:193-5.
[36] Greer JM, Capecchi MR. Hoxb8 is required for normal grooming
behavior in mice. Neuron 2002;33(1):23-34.
[37] Rauch SL, Dougherty DD, Malone D, Rezai A, Friehs G, Fischman
AJ, et al. A functional neuroimaging investigation of deep brain
stimulation in patients with obsessive-compulsive disorder. J Neurosurg
2006;104(4):558-65.
[38] Saxena S, Brody AL, Schwartz JM, Baxter LR. Neuroimaging and
frontal-subcortical circuitry in obsessive-compulsive disorder. Br J
Psychiatry Suppl 1998(35):26-37.
[39] Chamberlain SR, Fineberg NA, Blackwell AD, Robbins TW, Sahakian
BJ. Motor inhibition and cognitive flexibility in obsessive-compulsive
disorder and trichotillomania. Am J Psychiatry 2006;163:1282-4.
[40] Arnold LM, McElroy SL, Mutasim DF, Dwight MM, Lamerson CL,
Morris EM. Characteristics of 34 adults with psychogenic excoriation.
J Clin Psychiatry 1998;59:509-14.
[41] Wilhelm S, Keuthen NJ, Deckersbach T, Engelhard IM, Forker AE,
Baer L, et al. Self-injurious skin picking: clinical characteristics and
comorbidity. J Clin Psychiatry 1999;60(7):454-9.
[42] Potenza MN, Koran LM, Pallanti S. The relationship between impulse-
control disorders and obsessive-compulsive disorder: a current under-
standing and future research directions. Psychiatry Res 2009;170:22-31.
567
[43] Kim SW, Grant JE. Personality dimensions in pathological gambling
disorder and obsessive-compulsive disorder. Psychiatry Res 2001;104:
205-12.
[44] Cunningham-Williams RM, Cottler LB, Compton WM, Spitznagel
EL. Taking chances: problem gamblers and mental health disorders—
results from the St. Louis Epidemiologic Catchment Area Study. Am J
Public Health 1998;88:1093-6.
[45] Potenza MN, Steinberg MA, Skudlarski P, Fulbright RK, Lacadie CM,
Wilber, et al. Gambling urges in pathological gamblers: an fMRI study.
Arch Gen Psychiatry 2003;60:828-36.
[46] Grant JE. Family history and psychiatric comorbidity in persons with
kleptomania. Comp Psychiatry 2003;44:437-41.
[47] Bohne A, Keuthen N, Wilhelm S. Pathologic hairpulling, skin picking,
and nail biting. Ann Clin Psychiatry 2005;17(4):227-32.
[48] Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin RD,
Stein DJ, et al. Trichotillomania learning center-scientific advisory
board: the trichotillomania impact project (TIP): exploring phenom-
enology, functional impairment, and treatment utilization. J Clin
Psychiatry 2006;67(12):1877-88.
[49] Flessner CA, Woods DW. Phenomenological characteristics, social
problems, and the economic impact associated with chronic skin
picking. Behav Modif 2006;30:944-63.
[50] Abramowitz JS, Taylor S, McKay D. Obsessive-compulsive disorder.
Lancet 2009;374:491-9.
[51] Karno M, Golding JM, Sorenson SB, Burnam A. The epidemiology of
obsessive-compulsive disorder in five US communities. Arch Gen
Psychiatry 1988;45:1094-9.
[52] Weissman MM, Bland RC, Canino GJ, et al. The cross national
epidemiology of obsessive-compulsive disorder: the cross national
collaborative group. J Clin Psychiatry 1994;55(Suppl 3):5-10.
[53] Torres RA, Prince MJ, Bebbington PE, Brugha D, Brugha TS, Farrell
M, et al. Obsessive-compulsive disorder: prevalence, comorbidity,
impact, and help-seeking in the British National Psychiatric Morbidity
Survey of 2000. Am J Psychiatry 2006;163:1978-85.
[54] Noshirvani HF, Kasvikis Y, Marks IM, Tsakiris F, Monteiro WO.
Gender-divergent aetiological factors in obsessive-compulsive disor-
der. Brit J Psychiatry 1991;158:260-3.
[55] Castle DJ, Deale A, Marks IM. Gender differences in obsessive-
compulsive disorder. Austr N Z J Psychiatry 1995;29:114-7.
[56] Lensi P, Cassano GB, Correddu G, Ravagli S, Kunovac JL, Akiskal
HS. Obsessive-compulsive disorder: familial-developmental history,
symptomatology, comorbidity and course with special reference to
gender-related differences. Brit J Psychiatry 1996;169:101-7.
[57] Bogetto F, Venturello S, Albert U, Maina G, Ravizza L. Gender-related
differences in obsessive-compulsive disorder. Eur Psychiatry 1999;14:
434-41.
[58] Hantouche EG, Bourgeois ML, Lancrenon S, Bouhassira M.
Troubles et syndromes obsessionnels-compulsifs: influence du
sexe sur l'expression clinique. Ann Médico-Psychologiques 1996;
154:417-25.
[59] Faravelli C, Salvatori S, Galassi F, Aiazzi L, Drei C, Cabras P.
Epidemiology of somatoform disorders: a community survey in
Florence. Soc Psychiatry Psychiatr Epidemiol 1997;32(1):24-9.
[60] Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of body
dysmorphic disorder in a community sample of women. Am J
Psychiatry 2001;158(12):2061-3.
[61] Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brahler E. The
prevalence of body dysmorphic disorder: a population-based survey.
Psychol Med 2006;36:877-85.
[62] Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic
disorder. Psychopharmacol Bull 1995;31:279-88.
[63] Garcia AM, Freeman JB, Himle MB, Berman NC, Ogata AK, Ng J,
et al. Phenomenology of early childhood onset obsessive compulsive
disorder. J Psychopathol Behav Assess 2009;31(2):104-11.
[64] Leckman JF, McDougle CJ, Pauls DL, Peterson BS, Grice DE, King
RA, et al. Tic-related versus non-tic related obsessive-compulsive
disorder. In: Goodman WK, Rudorfer MV, & Mazur JD, editors.
568 L. Lovato et al. / Comprehensive Psychiatry 53 (2012) 562–568
Obsessive-Compulsive Disorder: Contemporary Issues in Treatment.
New York: Lawrence Erlbaum Associates; 2000. p. 43-68.
[65] Odlaug BL, Grant JE. Clinical characteristics and medical complica-
tions of pathologic skin picking. Gen Hosp Psychiatry 2008;30:61-6.
[66] Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and
comorbidity of 12-month DSM-IV disorders in the National
Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):
617-27.
[67] Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation:
clinical features, proposed diagnostic criteria, epidemiology and
approaches to treatment. CNS Drugs 2001;15:351-9.
[68] Keuthen NJ, Deckersbach T, Wilhelm S, Hale E, Fraim C, Baer L, et al.
Repetitive skin-picking in a student population and comparison with a
sample of self-injurious skin pickers. Psychosomatics 2000;41:210-5.
[69] Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: an
examination of the prevalence and severity in a community sample.
J Anxiety Disord 2009;23(3):314-9.
[70] Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of
trichotillomania in college students. J Clin Psychiatry 1991;52:415-7.
[71] Rothbaum BO, Shaw L, Morris R, Ninan PT. Prevalence of
trichotillomania in a college freshman population [letter]. J Clin
Psychiatry 1993;54:72.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.